Physician Compare National (NPI:1881954501)

HEALTHCARE PROVIDER: JEREMY THEISEN MD

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1881954501
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	1355571746
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20140304001840
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	THEISEN
	Individual professional last name
Provider First Name	JEREMY
	Individual professional first name
Provider Middle Name	D
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	UNIVERSITY OF OKLAHOMA COLLEGE OF MEDICINE
	Individual professional's medical school
Graduation Year	2012
	Individual professional's medical school graduation year
Primary Specialty	DIAGNOSTIC RADIOLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	ALLRAD PLLC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	0244484293
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	2
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	1900 N 14TH ST
	Group Practice or individual's line 1 address
City	PONCA CITY
	Group Practice or individual's city
State	OK
	Group Practice or individual's state
Zip Code	746012035
	Group Practice or individual's zip code (9 digits when available)
Phone Number	8003185578
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	370006
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	PONCA CITY MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	370049
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	STILLWATER MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	370215
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	OKLAHOMA HEART HOSPITAL, LLC
	Legal business name of hospital where individual professional provides service 3
Professional Accepts Medicare Assignment	Y